Our Bodies, Ourselves (100 page)
Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
There are several different ways to end the pregnancy. Medical treatment, which can be used only early in the pregnancy (generally before ten weeks), involves taking a drug, such as misoprostol, that causes uterine contractions and expulsion. In early pregnancy loss, this works more than 80 percent of the time, but failure rates are higher after about ten weeks.
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Surgical procedures include what is commonly referred to as a D&C (dilation and curettage), D&E (dilation and evacuationâused when the pregnancy is further along), or MVA (manual vacuum aspiration). These are all suction (aspiration) techniques that remove the pregnancy tissue, and they can be performed on an outpatient basis in a clinic, obstetrical office, hospital, or emergency room.
If you miscarry naturally or take medication, you will probably not be in a health care facility when the miscarriage begins. The process may be over in a day, or it may take several days. It is best to work with your doctor or midwife, since there is a risk that the bleeding will be heavy enough to necessitate an emergency procedure to complete the miscarriage. The fetus, amniotic sac, and placenta, along with a large amount of blood, will be expelled.
If you are less than eight weeks pregnant when the miscarriage occurs, the expelled tissue may look no different from heavy menstrual bleeding. If you have reached eight to ten weeks, more tissue will be expelled and miscarrying can be more painful. In this instance, if you have chosen to allow the miscarriage to occur spontaneously, try to arrange for a trusted, knowledgeable person to be with you through the processâand throughout the night, if needed. If you were planning on having a doula for your birth, consider arranging to have one help you through this. Think about where you will be most comfortable, and have supplies such as bed liners, sanitary pads, and hot water bottles or a heating pad on hand. You may want to ask your provider to prescribe pain medication in case you need it.
I was much better prepared for my second home miscarriage. My doctor had provided me with good pain medicine, and I was better prepared for dealing with all the blood. I had also been informed about how to tell if the amount of bleeding was dangerous. But I was alone, and it was a horrible thing to go through on my own. I really wish I'd had sense enough to make sure I had a friend with me to hold my hand or rub my back or bring me tea during those horrible hours
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© Fadil Berisha
“I EXPECTED TO HEAR THE BABY'S HEART BEAT.”
CATHERINE MCKINLEY
It took me eight months to conceive. Then suddenly I was having my encounter with the magical: a routine eight-week sonogram where I expected to hear the baby's heartbeat for the first time. My ob-gyn tried to mask his concern as he moved the wand across my quiet belly. He was strangely nonchalant as he told me that the office equipment was not always able to get sensitive readings early in pregnancy. He wrote out a referral for a hospital sonogram, and I tried to brush off my anxiety.
The radiologist performing the sonogram was very pregnant. I laughed at her crankiness because she was so stunning, with a stomach so large her belly button was pointing toward the floor. But then her body almost seemed to be mocking me as she told me that she was unable to find a heartbeat. “You've miscarried,” she said emotionlessly. It was difficult to process what she was saying. There had been no sign of blood; my body had not pushed out anything.
For weeks I'd felt this blooming feeling. But the night before, I had noticed that my skin had a funny new smell and I was suddenly feeling achy all over. Now I felt my body turning in on itself, betraying itself. I was admitted to the hospital for a D&C the next afternoon. That wait and the days after were some of the hardest moments of my journey to motherhood.
The loss roused old griefs: the eight months of wild fear that conception was impossible; the legacy of an illegal abortion, registered as a D&C while I was a college exchange student in Jamaica; birth family lost through adoption; and later the family I recovered whose inabilities rendered them as good as lost to me. An older friend who had had five children and twice as many pregnancies told me to embrace the heartache; I was being seasoned for motherhood. “You won't always get it easy,” she said, “But the difficulty is what gives you the desire and the heart to mother better.”
I got pregnant two months later and held my breath until the end of my first trimester. I was healthy and enjoying my pregnancy, but there was that lingering grief. I have come to like the idea of being seasoned. All of the trials have inscribed a kind of passion and will in my mothering.
DEALING WITH THE REMAINS OF THE PREGNANCY
If you are about to miscarry, you may want to think about what to do with the remains of the pregnancy. Some people collect it in a clean container and take it to a hospital-based laboratory so tests can be done to try to determine the cause. Others choose to treat it ritually. Share Pregnancy & Infant Loss Support (nationalshare.org) has information on both of these options.
There will be some blood clots, and you may notice tissue that is firmer or lumpy-looking, which is placental, or afterbirth, tissue. You may or may not see tissue that looks like an embryo or fetus.
Once everything in your uterus has been expelled, bleeding will continue, lessening over several days. If bleeding increases or stays bright red, or if you have foul-smelling discharge or a fever, contact your health care provider. If fetal tissue remains in your uterus, your provider can perform a D&C or a D&E to remove it, so as to prevent infection. These procedures involve dilating the cervix and using suction and/or a medical instrument to remove remaining fetal and placental tissue.
TESTING FOR CAUSES OF MISCARRIAGE
If you have a second-trimester miscarriage or have had two or more earlier miscarriages, medical tests to help identify the cause are recommended. If you are at home when you miscarry, you may be able to collect fetal or afterbirth tissue in a clean container for examination at a hospital-based laboratory. Blood tests may identify or rule out hormonal, immunological, or chromosomal abnormalities in the parents. Examinations of the uterus by ultrasound, hysteroscopy or hysterosalpingography or an endometrial biopsy may also provide important information.
It may be useful to arrange an after-loss visit with your doctor or nurse clinician to discuss any results. Ask for a copy of the pathology report, and ask for a full explanation of all terminology. If your report does indicate a cause of your miscarriage, the information will be important in determining if there is a risk of another miscarriage in the future. Even if the cause cannot be determinedâwhich is often the caseâyou may be able to rule out likely causes of repeat miscarriage and at least know that you have done all you can to get an answer.
Once bleeding has ceased and the cervix is closed, you can have sexual penetration without risk of infection. Since it is difficult to know when the cervix has completely closed, most providers recommend waiting two weeks. A repeat blood pregnancy test after a few weeks is important to make sure your hormone levels are normal. If you feel dizzy or tired, ask to be checked for anemia.
If you do not know your blood type, get a blood test within a few days of miscarrying. If your blood type is Rh-negative, you may need a shot of Rh immune globulin within seventy-two hours of the miscarriage, as if you were carrying an Rh-positive fetus, there is a small chance that you were exposed to Rh-positive blood cells from the fetal tissue during the miscarriage. The shot prevents your body from producing antibodies to Rh-positive blood that could harm a fetus during a future pregnancy.
Physical recovery from a miscarriage ranges from a few days to a couple of weeks. Your period will likely return within four to six weeks. Emotional recovery often takes longer. Give yourself time to grieve, search for medical explanations if there are any, and seek out other women who have miscarried. Remember that most miscarriages are single episodes and do not mean that you will have another.
In an ectopic pregnancy, the fertilized egg implants outside the uterus, usually in the fallopian tube, where it cannot develop normally. This can be a life-threatening condition requiring immediate treatment. Ectopic pregnancies occur in about one in fifty to one in one hundred pregnancies.
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The rate of ectopic pregnancy has increased over the past several decades, most likely because women are conceiving at older ages and more women are using advanced reproductive technologiesâboth risk factors for ectopic pregnancy. Most ectopic pregnancies are caused by an infection or inflammation of the fallopian tube, scar tissue or adhesions from previous tubal or pelvic-area surgeries, or a tubal abnormality. If you have had a previous ectopic pregnancy, pelvic surgery, or pelvic inflammatory disease, or if you conceived using assisted reproductive techniques, your risk of having an ectopic pregnancy is higher.
RECURRENT PREGNANCY LOSS
A minority of women experience multiple miscarriages or later losses and are unable to carry a pregnancy to term. Pregnancy loss is considered recurrent when a woman has had more than two losses. Between 50 and 75 percent of recurrent loss remains unexplained. However, for known causes, some treatments may be available. For more information, see “Patients' Fact Sheet: Recurrent Pregnancy Loss,” at the American Society for Reproductive Medicine's website, asrm.org, and “Recurrent Early Pregnancy Loss” at emedicine.medscape.com/article/260495-overview.
If you have had multiple losses, support is crucial.
Friends encouraged me to call their friends who had been through similar situations. This helped me tremendously. I loved talking to the woman in Oregon who had had four miscarriages before they discovered she had a blood-clotting disorder, or the woman in Boston who had three miscarriages and now had two small boys. These women became my friends.
If you have an ectopic pregnancy, you will have a positive pregnancy test and may feel all the usual signs of early pregnancy. Vaginal bleeding, dizziness, weakness, and gastrointestinal discomfort are common early symptoms. As the pregnancy progresses, the pressure in the tube or abdomen may cause stabbing pains, cramps, pain in your shoulder, or a dull ache that may vary in intensity and come and go. It
is critical to contact your provider if you have vaginal bleeding and/or sharp pain in the pelvic area, abdomen and/or neck and shoulders. If an ectopic pregnancy is not diagnosed early, the fallopian tube can rupture, causing severe blood loss and shock.
If you have any of the symptoms of ectopic pregnancy, your health care provider should check your hormone levels every two to three days and do a vaginal ultrasound as early as possible (at about six weeks). Ectopic pregnancy is occasionally misdiagnosed as an early miscarriage. This is why your provider may ask you to get a blood pregnancy test after a suspected miscarriage. The test can help confirm the presence or absence of residual fetal tissue.
If an ectopic pregnancy is found early, physicians can give you the drug methotrexate, which dissolves the embryonic tissue. If your pregnancy is more advanced, you may need a laparoscopy, which requires small incisions in your abdomen to insert a fiber-optic light (laparoscope) and other instruments to view the pelvic area and to remove the embryonic tissue. Doctors will try to save the fallopian tube if it is possible to do so. In some cases, laparoscopy is unsuccessful or unsafe (if, for example, the fallopian tube has ruptured), and then the surgical procedure is a laparotomy, which involves a larger incision and does not involve fiber-optic light. With either a laparoscopy or a laparotomy, the whole tube can be removed if necessary. Blood tests will be performed to check changes in your levels of hCG (human chorionic gonadotropin, the hormone produced by placental tissue) after any of these treatments in order to confirm that no ectopic tissue remains.
The loss of an ectopic pregnancy may bring on feelings like those that follow miscarriage, as well as fear that such a pregnancy could happen again. If you have had internal bleeding or a traumatic emergency surgery, seek additional support and talk with your provider about how this may affect future conception and pregnancies and how to minimize future risks.
Molar pregnancies (also called gestational trophoblastic disease and hydatidiform mole) happen when the cells that are supposed to develop into the placenta instead develop into a tumor made of trophoblastic (placental) cells. The growth must be removed so that it does not spread. The chances of a molar pregnancy are very smallâabout 1 in every 1,000 to 1,200 pregnancies.
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A partial molar pregnancy means there is some fetal development along with an abnormal placenta. In a complete molar pregnancy, there is no fetal development, just an abnormal placenta.
Signs and symptoms, usually identified through routine pregnancy visits, include first-trimester vaginal bleeding, high blood pressure, and a uterus that is too large for the gestational age. Molar pregnancies are treated by a D&C to remove the abnormal tissue and, in rare cases, by chemotherapy to treat any remaining abnormal cells. Close follow-up after a D&C is very important to ensure that no more abnormal tissue remains. A molar pregnancy does not affect your chances of having a subsequent normal pregnancy. But, like any other pregnancy loss, it is likely to bring grief, fears, and questions. In addition, after a molar pregnancy, you should avoid getting pregnant again for a period of time (up to a year), because the best way to know whether all the abnormal tissue is gone is to measure hCG, and a new pregnancy will make that test useless.